- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $549.54 / $1,288.25
| Professional | | $389.05 | $549.54 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $436.52 / $870.96
| Professional | | $354.81 | $436.52 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $724.44 / $912.01
| Professional | | $478.63 | $724.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $1,000.00
| Professional | | $389.05 | $602.56 | $1,000.00 |